Practice variation in late-preterm deliveries: a physician survey.

OBJECTIVE: Late-preterm (LPT) neonates account for over 70% of all preterm births in the US. Approximately 60% of LPT births are the result of non-spontaneous deliveries. The optimal timing of delivery for many obstetric conditions at LPT gestations is unclear, likely resulting in obstetric practice variation. The purpose of this study is to identify variation in the obstetrical management of LPT pregnancies. STUDY DESIGN: We surveyed obstetrical providers in North Carolina identified from North Carolina Medical Board and North Carolina Obstetrical and Gynecological Society membership lists. Participants answered demographic questions and six multiple-choice vignettes on management of LPT pregnancies. RESULT: We obtained 215/859 (29%) completed surveys which are as follows: 167 (78%) from obstetrics/gynecology, 27 (13%) from maternal-fetal medicine, and 21 (10%) from family medicine physicians. Overall, we found more agreement on respondents' management of chorioamnionitis (97% would proceed with delivery), mild pre-eclampsia (84% would delay delivery/expectantly manage) and fetal growth restriction (FGR) (80% would delay delivery/expectantly manage). We found less agreement on the management of severe preeclampsia (71% would proceed with delivery), premature preterm rupture of membranes (69% would proceed with delivery) and placenta previa (67% would delay delivery/expectantly manage). Management of LPT pregnancies complicated by preterm premature rupture of membranes, FGR and placenta previa vary by specialty. CONCLUSION: Obstetrical providers report practice variation in the management of LPT pregnancies. Variation might be influenced by provider specialty. The absence of widespread agreement on best practice might be a source of modifiable LPT birth.

Should any workplace be exempt from smoke-free law: the Irish experience.

BACKGROUND: In 2004, the Irish Government introduced national legislation banning smoking in workplaces; with exemptions for "a place of residence". This paper summarises three Irish studies of exempted premises; prisons, psychiatric hospitals and nursing homes. METHODS: PM(2.5) and nicotine were measured in nursing homes and psychiatric hospitals, in addition to ultrafine particles in the hospitals. In the prisons, officers (n = 30) completed exhaled breath Carbon Monoxide (CO) measurements. Questionnaires determined officers' opinion on introducing smoking prohibitions in prisons. Nursing home smoking policies were examined and questionnaires completed by staff regarding workplace secondhand smoke (SHS) exposure. FINDINGS: Ultrafine particle concentrations in psychiatric hospitals averaged 130,000 cm(3), approximately 45% higher than Dublin pub (35.5 µg/m(3)) pre ban. PM(2.5) levels in psychiatric hospitals (39.5 µg/m(3)) were similar to Dublin pubs (35.5 µg/m(3)) pre ban. In nursing homes permitting smoking, similar PM(2.5) levels (33 µg/m(3)) were measured, with nicotine levels (0.57 µg/m(3)) four times higher than "non-smoking" nursing homes (0.13 µg/m(3)). In prisons, 44% of non-smoking officers exhibited exhaled breath CO criteria for light to heavy smokers. CONCLUSIONS: With SHS exposure levels in some exempted workplaces similar to Dublin pubs levels pre ban, policies ensuring full protection must be developed and implemented as a right for workers, inmates and patients.

Smoking, occupancy and staffing levels in a selection of Dublin pubs pre and post a national smoking ban, lessons for all.

BACKGROUND: On the 29th March 2004 the Irish government introduced a comprehensive workplace smoking ban to protect the health of workers. This study evaluates the impact the ban had on staffing levels, customer numbers and smoking rates in a sample of 38 public houses in Dublin. METHODS: A total of 38 public houses were visited prior to the introduction of the ban, each visit lasted at least three hours, and the number of staff, customers and the number of people smoking was recorded each hour. Follow-up visits were conducted exactly one year later, on the same day of the week and at the same time of day, allowing controlling for seasonal and weekday effects. RESULTS: There was a decrease (8.82%) in average staff levels while customer numbers increased by 11% and there was a dramatic reduction in numbers smoking on a visit to a pub (77.8%). CONCLUSIONS: The hospitality industry predicted major job losses as a consequence of the introduction of the smoking ban; this work has shown that there was no significant decrease in the number of staff employed or in customer numbers. There was full compliance, with no customers smoking inside the public houses following the introduction of the ban. The ban has been good for the industry, staff, and customers.

Bacterial vaginosis in climacteric and menopausal women.

The objective was to determine how frequently an abnormal vaginal flora occurred in women attending a menopause clinic and whether any abnormality might be related to a particular risk factor. Women completed a questionnaire on their gynaecological, sexual and medical history. Whether they were perimenopausal or postmenopausal was determined on the basis of symptomatology, duration of amenorrhoea and on a follicle-stimulating hormone (FSH) assay when clinically indicated. A speculum examination of the vagina was undertaken, at which time a smear of vaginal secretion was Gram stained and the bacterial flora graded as follows: grade 1, normal; grade 2, intermediate, and grade 3, bacterial vaginosis (BV). Of 100 women examined, 44 had grade 1 flora, 17 had grade 2 flora and 18 had BV. An apparent absence of, or very scanty, vaginal bacteria in which grading was not possible was found in 21 women. Women with BV had had more sexual partners than the others, but otherwise there were no discernible factors associated with the occurrence of BV. Women with vaginal atrophy were more likely to have an apparent absence of vaginal bacteria, but a few had BV.

Rab4 affects both recycling and degradative endosomal trafficking.

The small GTPases Rab4, Rab5 and Rab7 are endosomal proteins which play important roles in the regulation of various stages of endosomal trafficking. Rab4 and Rab5 have both been localized to early endosomes and have been shown to control recycling and endosomal fusion, respectively. Rab7, a marker of the late endosomal compartment, is involved in the regulation of the late endocytic pathway. Here, we compare the role of Rab4, Rab5 and Rab7 in early and late endosomal trafficking in HeLa cells monitoring ligand uptake, recycling and degradation. Expression of the Rab4 dominant negative mutant (Rab4AS22N) leads to a significant reduction in both recycling and degradation while, as expected, Rab7 mutants exclusively affect epidermal growth factor (EGF) and low density lipoprotein degradation. As also expected, expression of the dominant negative Rab5 mutant perturbs internalization kinetics and affects both recycling and degradation. Expression of Rab4WT and dominant positive mutant (Rab4AQ67L) changes dramatically the morphology of the transferrin compartment leading to the formation of membrane tubules. These transferrin positive tubules display swellings (varicosities) some of which are positive for early endosomal antigen-1 and contain EGF. We propose that the Rab4GTPase is important for the function of the early sorting endosomal compartment, affecting trafficking along both recycling and degradative pathways.

The small GTPase Rab4A interacts with the central region of cytoplasmic dynein light intermediate chain-1.

Rab4 belongs to the Rab family of small GTPases involved in the regulation of intracellular transport, and has been localized to early endosomes. We have employed the yeast two-hybrid system to identify proteins that specifically interact with Rab4AQ67L, a GTPase-deficient mutant form of Rab4A. Screening a mouse embryo cDNA library identified a clone (M449) that interacted with Rab4A in a nucleotide-dependent fashion. Data base searches identified this clone as the mouse cytoplasmic dynein light intermediate chain-1 (LIC-1). Based on this finding, the full-length equivalent human cytoplasmic dynein LIC-1 was isolated by PCR. When Rab4A was overexpressed together with either M449 or dynein LIC-1 in HeLa cells, the proteins were found to colocalize in the perinuclear region. We characterize the localization of both overexpressed human dynein LIC-1 and the endogenous protein with respect to microtubules and show that it concentrates to the microtubule-organizing center and mitotic spindle. Additionally, GFPRab4A endosomes localize to microtubules and are redistributed by nocodazole treatment. This is the first described interaction between cytoplasmic dynein, a retrograde motor protein, and a Rab protein.

The adolescent pilon fracture: management and outcome.

Pilon fractures in the adolescent are complicated by the presence of the adjacent physis. These fractures usually result from high-energy trauma, frequently associated with soft-tissue trauma, further potentiating treatment difficulties. Although rare, such fractures are associated with a high complication rate, including physeal arrest. It was the objective of this review to increase awareness of this fracture pattern in the adolescent, to determine the types of complications in this difficult group, and to develop a treatment plan to improve the outcome of treatment. Seven children, with a total of eight pilon fractures were treated at a major pediatric tertiary referral center over the past 10 years. The average age of the children was 15 years 10 months (range, 13 years 6 months to 17 years 7 months). The average length of follow-up was 16 months (range, 3 months and 3 years 10 months). There were three Reudi type II equivalent fractures and two Reudi type III equivalent injuries. Three fractures did not fit the Reudi classification system as there was an associated ankle dislocation. All fractures were treated with open reduction and internal fixation. There were two cases of posttraumatic osteoarthritis and one physeal arrest. Results were good to excellent in 63% of cases. A new classification system for pediatric pilon fractures has been proposed.

Are seminal fluid microorganisms of significance or merely contaminants?

OBJECTIVE: To determine the contribution of urethral and skin flora to seminal fluid cultures and the relation between bacteriospermia and seminal leukocytes. DESIGN: Prospective study. SETTING: IVF-ET unit at a university teaching hospital. PATIENT(S): Sixty men starting an IVF-ET program. INTERVENTION(S): Culture of sequential first-catch urine, midstream urine, and semen samples with evaluation of seminal leukocytes. MAIN OUTCOME MEASURE(S): A comparison of microbes from first-catch urine, midstream urine, and semen samples and the correlations of seminal microbes, elevated leukocyte concentrations, and pregnancy. RESULT(S): Microorganisms were detected in 37% of first-catch urine samples, 27% of midstream urine samples, and 51% of semen samples. Most microorganisms were gram-positive microbes and were common to both urine and semen samples. Mean and median leukocyte concentrations were 0.98 x 10(6)/mL and 0.10 x 10(6)/mL, respectively. There was no correlation between seminal microbes and raised leukocytes or between leukocytospermia and/or bacteriospermia and pregnancy. CONCLUSION(S): Microorganisms are commonly found in insignificant quantities in the semen of asymptomatic men. The frequent isolation of gram-positive microbes common to both urine and semen and the absence of a correlation with raised leukocyte concentrations suggest that bacteriospermia most commonly represents contamination.

Inhaled nitric oxide in premature neonates with severe hypoxaemic respiratory failure: a randomised controlled trial.

BACKGROUND: Inhaled nitric oxide improves oxygenation and lessens the need for extracorporeal-membrane oxygenation in full-term neonates with hypoxaemic respiratory failure and persistent pulmonary hypertension, but potential adverse effects are intracranial haemorrhage and chronic lung disease. We investigated whether low-dose inhaled nitric oxide would improve survival in premature neonates with unresponsive severe hypoxaemic respiratory failure, and would not increase the frequency or severity of intracranial haemorrhage or chronic lung disease. METHODS: We did a double-blind, randomised controlled trial in 12 perinatal centres that provide tertiary care. 80 premature neonates (gestational age < or = 34 weeks) with severe hypoxaemic respiratory failure were randomly assigned inhaled nitric oxide (n=48) or no nitric oxide (n=32, controls). Our primary outcome was survival to discharge. Analysis was by intention to treat. We studied also the rate and severity of intracranial haemorrhage, pulmonary haemorrhage, duration of ventilation, and chronic lung disease at 36 weeks' postconceptional age. FINDINGS: The two groups did not differ for baseline characteristics or severity of disease. Inhaled nitric oxide improved oxygenation after 60 min (p=0.03). Survival at discharge was 52% in the inhaled-nitric-oxide group and 47% in controls (p=0.65). Causes of death were mainly related to extreme prematurity and were similar in the two groups. The two groups did not differ for adverse events or outcomes (intracranial haemorrhage grade 2-4, 28% inhaled nitric oxide and 33% control; pulmonary haemorrhage 13% and 9%; chronic lung disease 60% and 80%). INTERPRETATION: Low-dose inhaled nitric oxide improved oxygenation but did not improve survival in severely hypoxaemic premature neonates. Low-dose nitric oxide in the most critically ill premature neonates does not increase the risk of intracranial haemorrhage, and may decrease risk of chronic lung injury.

Bacterial vaginosis in lesbians: evidence for lack of sexual transmission.

The effect of non-heterosexual factors on the vaginal flora has been studied. Ninety-one lesbians attending a specialist genitourinary medicine service for lesbians were studied. Bacterial vaginosis (BV) was diagnosed in 51.6% of them. While most of the women had previously had a male sexual partner, the presence of BV was not associated with a male sexual partner in the previous 12 months. A detailed analysis of lesbian sexual practices in the group did not relate BV to any sexual practice which would have the propensity to pass vaginal secretions from one to the other.

An analysis of an air-ambulance program for children.

Air-ambulance services are extremely expensive to operate and maintain. The value of their existence has been questioned in this era of rationalization and downsizing. We examined the cost, safety, flight crew composition, types of trauma, and effectiveness of our air-ambulance program at the Children's Hospital of Eastern Ontario (CHEO) over a 3-year period, 1994-1997. During this time, 392 children were aeroevacuated to CHEO, 113 surgical (29%), 136 medical (35%), and 143 neonates (36%). Of the surgical cases, 43% were transferred for orthopaedic trauma, the commonest being fractured femur, 23% for general surgical cases, most common being thoracoabdominal trauma, and 22% for neurosurgical reasons, most commonly basilar skull fractures. The average response time (time from which the call was received to the time when the helicopter reached the patient site) for all of the cases was 46 min. The average travel time (time from departure of patient site to arrival at CHEO) for these same cases was 25.59 min. The air-ambulance program for children in the Ottawa-Carleton Eastern Ontario areas, was found to be safe, effective, and allowed earlier specialized medical care to be provided.

Effect of initial nitric oxide concentration on outcome in infants with persistent pulmonary hypertension of the newborn.

A randomized nonblinded comparison of two treatment groups was performed to determine whether treatment of infants with persistent pulmonary hypertension of the newborn using a continuous 6-ppm dose of inhaled nitric oxide (iNO) changes the likelihood of death or utilization of extracorporeal membrane oxygenation (ECMO) when compared to infants treated with 20 ppm iNO for 4 h followed by 6 ppm. Twenty-nine infants with a gestational age >/=34 weeks and a diagnosis of persistent pulmonary hypertension of the newborn were enrolled during the 3- year study period. The relative risk (20/6 vs. 6 ppm) for treatment with ECMO was 3.11 (p = 0.02), for death it was 2.80 (p = 0.32), and for either death or ECMO it was 3.42 (p = 0. 006). There was no apparent advantage of treatment with a higher dosage of iNO at the initiation of therapy in the reduction of death or utilization of ECMO. These data suggest that a continuous lower dose of iNO results in a comparable improvement in oxygenation as a short exposure of higher dose iNO at the initiation of therapy.

Air bags and children: a potentially lethal combination.

Air bags have been responsible for saving thousands of lives since their introduction in the early 1970s. Now, however, it has become apparent that under certain conditions, these restraint mechanisms designed to save lives have in fact been the cause of needless morbidity and mortality in children. We reviewed 13 children injured by air bags in Canada, where seat belt wear is mandatory for all occupants. Although 12 of the children sustained relatively minor air bag trauma, one child was killed by the air bag deployment, sustaining an occipital-C1 dislocation. The pediatric population is at particular risk as many parents continue to unwittingly place their children in the front seat and thus in jeopardy of sustaining air bag-induced injuries should a collision occur.

Distinct Rab-binding domains mediate the interaction of Rabaptin-5 with GTP-bound Rab4 and Rab5.

Rabaptin-5 functions as an effector for the small GTPase Rab5, a regulator of endocytosis and early endosome fusion. We have searched for structural determinants that confer functional specificity on Rabaptin-5. Here we report that native cytosolic Rabaptin-5 is present in a homodimeric state and dimerization depends upon the presence of its coiled-coil predicted sequences. A 73 residue C-terminal region of Rabaptin-5 is necessary and sufficient both for the interaction with Rab5 and for Rab5-dependent recruitment of the protein on early endosomes. Surprisingly, we uncovered the presence of an additional Rab-binding domain at the N-terminus of Rabaptin-5. This domain mediates the direct interaction with the GTP-bound form of Rab4, a small GTPase that has been implicated in recycling from early endosomes to the cell surface. Based on these results, we propose that Rabaptin-5 functions as a molecular linker between two sequentially acting GTPases to coordinate endocytic and recycling traffic.

Targeting determinants and proposed evolutionary basis for the Sec and the Delta pH protein transport systems in chloroplast thylakoid membranes.

Transport of proteins to the thylakoid lumen is accomplished by two precursor-specific pathways, the Sec and the unique Delta pH transport systems. Pathway selection is specified by transient lumen-targeting domains (LTDs) on precursor proteins. Here, chimeric and mutant LTDs were used to identify elements responsible for targeting specificity. The results showed that: (a) minimal signal peptide motifs consisting of charged N, hydrophobic H, and cleavage C domains were both necessary and sufficient for pathway-specific targeting; (b) exclusive targeting to the Delta pH pathway requires a twin arginine in the N domain and an H domain that is incompatible with the Sec pathway; (c) exclusive targeting to the Sec pathway is achieved by an N domain that lacks the twin arginine, although the twin arginine was completely compatible with the Sec system. A dual-targeting signal peptide, constructed by combining Delta pH and Sec domains, was used to simultaneously compare the transport capability of both pathways when confronted with different passenger proteins. Whereas Sec passengers were efficiently transported by both pathways, Delta pH passengers were arrested in translocation on the Sec pathway. This finding suggests that the Delta pH mechanism evolved to accommodate transport of proteins incompatible with the thylakoid Sec machinery.

Spermatozoal DNA flow cytometry and recurrent miscarriage.

Clinical investigations of the male partner of couples with recurrent miscarriage involves investigation of abnormalities in paternal chromosomes. This route of investigation does not include analysis of semen parameters. This investigation was conducted to evaluate DNA flow cytometry profiles of spermatozoa following staining with propidium iodide of couples attending the Pregnancy Loss Clinic for recurrent miscarriage. Ejaculates of 21 men were included in this study. DNA fluorescence was measured on the Becton Dickinson Fac Star Plus. Data were correlated with spermiogram parameters. The neat semen median minus peak channel values were negatively correlated with motility (p < .05). Therefore, DNA flow cytometry can provide confirmatory evidence for conventional semen analysis and is useful as a preliminary screening procedure for clinical management of the couple. It could also be used in association with programs for the assessment of possible reproductive toxicity and infertility in couples with recurrent miscarriage.

Management of female genital mutilation: the Northwick Park Hospital experience.

OBJECTIVE: To outline the problems associated with female genital mutilation and to highlight the need for deinfibulation before delivery. DESIGN: A review of women attending a newly established African Well Woman Clinic. Age at infibulation, gravidity of clinic attenders and adequacy of introitus for management of labour were assessed. SETTING: Northwick Park Hospital, Harrow, Middlesex. SUBJECTS: Fifty women attending a newly established African Well Woman Clinic, of whom 13 were nulliparous, 14 were primigravid and 23 were multigravid. RESULTS: The average age at which infibulation had occurred was 6.7 years. At the time of clinic attendance the mean age of pregnant and nonpregnant patients was 26 and 23.3 years, respectively. Of the 14 primigravid patients, only 50% had an adequate introitus to allow management of the first and second stages of labour. Five had deinfibulation performed antenatally or at delivery. Ninety-three percent of the primigravid patients and 74% of the multigravid patients had a vaginal delivery. CONCLUSIONS: We believe that the Northwick Park Hospital management policy for infibulated women closely mirrors the cultural practices in Somalia. The policy also improves obstetric management of infibulated patients. Twenty-six percent of referrals were of nonpregnant women, and this practice is to be encouraged.